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PS-086 Errors associated with a computerised physician order entry system: incorrect non-daily medicines requests
  1. JA Dominguez Menendez,
  2. S Vallinas Hidalgo,
  3. N Pardo Santos,
  4. B Balzola Regout,
  5. LM Mendarte Barrenechea,
  6. MJ Yurrebaso Ibarreche
  1. Basurto Hospital, Pharmacy, Bilbao, Spain


Background Computerised physician order entry (CPOE) systems prevent medicines being requested without a prescription. However, potential errors still occur due to incorrect treatment requests.

Purpose To quantify and analyse potential medicines errors associated with incorrect nurse requests for medicines scheduled less often than every day.

Material and methods Prospective observational study carried out over three months in units using CPOE and unit-dose medicines dispensing systems. Data about non-daily medicines schedules (every 48 or 72h, weekly,..) requested by nurses were collected.

Results 45 medicines requests were checked during this period. Classified by schedule: 14 weekly, 7 every 48 h, 7 biweekly, 5 single dose, 4 Monday-Wednesday-Friday, 8 others. Classified by medicine: 15 epoetin alfa, 4 weekly alendronate, 4 intramuscular risperidone, 4 intramuscular paliperidone, 18 others. Classified by cause: 27 not dispensed in unit doses due to stability or other special issue, 9 starts of treatment, 6 with errors in the requests, 2 dispensing errors, 1 missed medicine.

A total of 6 incorrect requests were detected (13%): weekly epoetin alfa, weekly alendronate, prednisone every 48 h, mercaptopurine every 48 h, furosemide every 48 h, buprenorphine every 72 h. Only one of these errors occurred in medicines not dispensed in a unit dose (1 of 27 requests), and the others in unit-dose dispensed medicines (5 of 18 requests).

All the incorrect requests had been prescribed correctly.

Conclusion CPOE reduces potential errors associated with medicines, such as requests for medicines that have not been prescribed. However, errors associated with medicines requests are still happening. These incorrect requests occur despite a correct prescription, therefore an exhaustive revision of the system for requesting non-daily medicines is necessary to prevent this source of errors.

References and/or acknowledgements No conflict of interest.

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